Provider Demographics
NPI:1447374160
Name:MALLIK, MANJIT S (DDS)
Entity type:Individual
Prefix:
First Name:MANJIT
Middle Name:S
Last Name:MALLIK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OTSEGO AVE
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8011
Mailing Address - Country:US
Mailing Address - Phone:631-242-4478
Mailing Address - Fax:631-643-2274
Practice Address - Street 1:9610 57TH AVE
Practice Address - Street 2:#2H
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3436
Practice Address - Country:US
Practice Address - Phone:718-271-3995
Practice Address - Fax:718-271-0021
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00899692Medicaid